What are the management options for patients with multiple uterine fibroids?

Management of Multiple Uterine Fibroids

Initial Treatment Approach

Medical management should be trialed first before pursuing invasive therapies for patients with multiple uterine fibroids, regardless of fertility desires. 1, 2, 3

The treatment algorithm depends critically on three factors: symptom type (heavy bleeding vs. bulk symptoms), fertility desires, and fibroid characteristics (size, number, location). 1, 3

First-Line Medical Management

For Heavy Menstrual Bleeding

• Start with NSAIDs, tranexamic acid, combined hormonal contraceptives, or levonorgestrel-releasing IUD as first-line options for bleeding control. 2, 3
• The levonorgestrel IUD is particularly effective for long-term management and should be strongly considered for patients not immediately desiring pregnancy. 2, 4
• Tranexamic acid provides an excellent nonhormonal alternative for patients who cannot or prefer not to use hormonal options, with significant reduction in menstrual blood loss. 2, 3

For Bulk Symptoms (Pressure, Pain, Bladder/Bowel Dysfunction)

• Oral GnRH antagonists (elagolix, relugolix, linzagolix) with hormone add-back therapy are the most effective medical option, reducing fibroid volume by 18-30%. 2, 3
• These agents offer advantages over parenteral GnRH agonists with rapid onset and oral administration. 2
• Critical caveat: Always use combination low-dose estrogen-progestin add-back therapy to prevent bone mineral density loss with GnRH antagonists. 2

Surgical Management Based on Fertility Desires

For Patients Desiring Future Pregnancy

• Laparoscopic or open myomectomy is the primary surgical option for symptomatic multiple fibroids in reproductive-age patients. 1, 3
• Open myomectomy should be preferred over laparoscopic approaches when dealing with multiple fibroids or very large uteri to ensure complete fibroid removal and adequate repair. 3
• For pedunculated submucosal fibroids <5cm causing bleeding, hysteroscopic myomectomy is first-line surgical therapy with shorter hospitalization and faster recovery. 1, 3
• Important pitfall: Fertility outcomes after myomectomy are modest—less than half of patients attempting conception achieve pregnancy, and less than half of these result in live birth. 3 Counsel patients accordingly.
• Warn patients about morcellation risks: In rare cases, fibroids may contain unexpected malignancy, and power morcellation can spread cancer cells, worsening prognosis. 4

For Patients Not Desiring Future Fertility

• Multiple equivalent options exist: laparoscopic/open myomectomy, medical management, MR-guided focused ultrasound (MRgFUS), or uterine artery embolization (UAE). 1
• Hysterectomy provides definitive resolution with patient satisfaction rates up to 90% and should be offered as the most effective treatment after counseling about alternatives. 3, 4
• UAE is an effective minimally invasive alternative improving symptoms and quality of life for up to 7 years, with a 7% reintervention rate for persistent symptoms. 3
• Critical caveat for UAE: Treatment failure rates are higher (23%) in patients under age 40 due to collateral vessel recruitment. 3

Special Clinical Scenarios

Multiple Fibroids with Concurrent Adenomyosis

• Medical management or UAE are the preferred initial approaches for patients with both conditions experiencing heavy bleeding or bulk symptoms. 1, 3
• Myomectomy is less effective in this population due to the diffuse nature of adenomyosis. 1

Postmenopausal Patients

• Hysterectomy is the appropriate next step for symptomatic postmenopausal patients after negative endometrial evaluation. 1, 3
• Expectant management is reasonable for asymptomatic fibroids as most decrease in size after menopause. 5

Preoperative Optimization

• Correct anemia before elective surgery using GnRH agonists/antagonists or selective progesterone receptor modulators, which effectively reduce bleeding and improve hemoglobin. 2, 4
• Use vasopressin, bupivacaine with epinephrine, misoprostol, peri-cervical tourniquet, or gelatin-thrombin matrix to reduce blood loss during myomectomy. 4
• Provide concurrent iron supplementation during preoperative medical therapy. 2

Critical Limitations to Communicate

• Most medical treatments provide only temporary symptom relief—symptoms typically recur rapidly after discontinuation. 2
• Fertility is suppressed during GnRH agonist/antagonist treatment, requiring discontinuation before attempting conception. 2
• MRgFUS has a higher reintervention rate (30%) compared to UAE (13%), making it less durable for multiple fibroids. 6
• Progesterone receptor modulators (ulipristal acetate) show promise but have limited U.S. availability due to hepatotoxicity concerns. 2, 6